Easy bruising resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sanjana Nethagani, M.B.B.S.[2]

Overview

Easy bruising is the bruising of skin with minor compression or pressure. When small capillaries of the superficial skin rupture from pressure or compression, petechiae occur, sometimes ecchymosis is also seen with insignificant trauma which is a bleed in the deeper layers in the skin. A wide variety of causes lead to easy bruising, some of which are clotting and bleeding disorders, platelet dysfunction, age related skin changes, and some forms of cancer such as leukemia.

Causes

Life threatening causes

• Thrombotic Thrombocytopenic Purpura
• Disseminated intravascular coagulation
• Leukemia
• Severe thrombocytopenia

Other causes

• Hemophilia A
• Hemophilia B
• Scurvy
• Von Willebrand disease
• Ehlers-Danlos syndrome
• Corticosteroid use
• Anticoagulant therapy
• Idiopathic Thrombocytopenic Purpura
• Henoch-Schonlein Purpura
• Vitamin K deficiency
• Liver disease
• Systemic Lupus Erythematosus
• Glanzmann Thrombasthenia
• Bernard-Soulier syndrome

For a full list of causes of easy bruising, click here.

Diagnosis

The algorithm below summarises approach to the different causes of easy bruising.

Detailed history: ❑ Is the bleeding over the limbs? ❑ Is there any bleeding in mucosal surfaces such as gums or oral mucosa? ❑ History of recent infections? ❑ Is there bleeding into the joints? ❑ Is there history of bruising after minor trauma in the past? ❑ Is there any associated rash? ❑ History of blood transfusions? ❑ History of bleeding after tooth extractions or surgeries ❑ Bleeding during menstrual cycle in women ❑ Drug history: Any use of the following in the past? Corticosteroids Heparin Warfarin Other anticoagulants Aspirin ❑ Family history of bleeding?

Characterize the symptoms ❑ Bruising with minor or no trauma ❑ Petechiae ❑ Gingival bleeding ❑ Menorrhagia ❑ Painful bleeding into joints

Initial investigations ❑ Complete blood count with platelet count ❑ PT/aPTT ❑ INR ❑ Liver function tests ❑ Thyroid function tests ❑ Renal function tests ❑ Peripheral smear ❑ Bleeding time ❑ Platelet function analyzer Other investigations ❑ Von Willebrand factor levels ❑ Factor VIII level ❑ Factor IX level ❑ Fibrinogen level ❑ ADAMTS13 level

Disorders of secondary hemostasis ❑ Abnormal PT/aPTT ❑ Abnormal factor assays ❑ Abnormal fibrinogen level

Decreased platelet count ❑ mild: 100,000 - 150,000 per µL ❑ moderate: 50,000 to 99,000 per µL ❑ severe: <50,000 per µL (may require transfusion)

Disorders of platelet function ❑ Prolonged bleeding time ❑ Thrombocytopenia ❑ Abnormal PFA-100 ❑ Abnormal Von Willebrand factor assay ❑ Abnormal Ristocetin induced platelet agglutination

Clotting factor disorders

Inherited

Acquired

❑ Von Willebrand disease * Abnormal Von Willebrand factor assay * Abnormal Glycoprotein 1b assay * Correction on ristocetin cofactor assay * Low factor VIII levels * Prolonged PTT ❑ Glanzmann's thrombasthenia * Abnormal platelet aggregation assays * Monoclonal antibody testing * Flow cytometry ❑ Bernard-Soulier syndrome * Giant platelets on peripheral smear * Abnormal ristocetin aggregation ❑ Oculocutaneous albinism/Hermansky-Pudlak syndrome * Absent dense bodies on electron microscopy of platelets * Abnormal platelet aggregation assays ❑ Chédiak-Higashi syndrome * Abnormal platelet aggregation assays * Defective platelet storage granules ❑ Isolated dense granule deficiency * Defective platelet aggregation * Decreased ADP/ATP ratio

❑ Uremia ❑ Acquired Von Willebrand disease ❑ Aspirin and other NSAIDs ❑ Glycoprotein IIb/IIIa inhibitors ❑ Cardiopulmonary bypass ❑ Dysproteinemia ❑ Myeloproliferative disorders ❑ Cardiopulmonary bypass ❑ Infections such as Dengue fever or Hepatitis C

Hemophilia A * Normal PT * Prolonged PTT * Abnormally low Factor VIII

Hemophilia B * Abnormally low Factor IX * Normal PT * Prolonged PTT

Hemophilia C * Prolonged aPTT * Abnormally low Factor XI

Low/undetectable fibrinogen * Afibrinogenemia * Hypofibrinogenemia * Hypodysfibrinogenemia

No abnormalities detected in initial analysis

❑ Consider other diagnoses ❑ Senile purpura ❑ Aplastic anemia ❑ Long term corticosteroid use ❑ Scurvy ❑ Vitamin K deficiency ❑ Domestic abuse ❑ Leukemia ❑ Meningococcal infection ❑ Ehlers-Danlos syndrome ❑ Alpha 2-antiplasmin deficiency ❑ Plasminogen activator inhibitor-1 deficiency ❑ Factor XIII deficiency ❑ Lupus anticoagulant ❑ Antiphospholipid syndrome ❑ ITP ❑ TTP/HUS ❑ Liver disease

Diagnostic clues

Shown below is a table summarizing different findings in easy bruising and their interpretation.

Laboratory findings	Associated conditions
Prolonged bleeding time	Defects in primary hemostasis
Prolonged clotting time	Defects in secondary hemostasis
Low platelet count	Thrombocytopenia, DIC, ITP, TTP, Aplastic anemia